R-2014-1795 - 9/25/2014 RESOLUTION NO. R-2014-1795
WHEREAS, the Area Agency on Aging offers funding for transportation services which
provides nutrition bus trips for seniors, and
WHEREAS, on January 24, 2013, the Council approved a Vendor Agreement with the Area
Agency on Aging for nutrition funding for the Demand Response Bus Service, and
WHEREAS, the City wishes to renew said Agreement regarding the Demand Response Bus
Service,Now Therefore
BE IT RESOLVED BY THE COUNCIL OF THE CITY OF ROUND ROCK, TEXAS,
That the Mayor is hereby authorized and directed to execute on behalf of the City related
documents regarding the Vendor Agreement with the Area Agency on Aging regarding the Demand
Bus Response Bus Service, a copy of same being attached hereto as Exhibit "A" and incorporated
herein for all purposes.
The City Council hereby finds and declares that written notice of the date, hour, place and
subject of the meeting at which this Resolution was adopted was posted and that such meeting was
open to the public as required by law at all times during which this Resolution and the subject matter
hereof were discussed, considered and formally acted upon, all as required by the Open Meetings Act,
Chapter 551, Texas Government Code, as amended.
RESOLVED this 25th day of September, 2014.
CrY)
ALAN MCGRAW, Mayor
City of Round Rock, Texas
ATTEST:
c5RIAA,-
' to IICE "
SARA L. WHITE, City Clerk
0112.1404;00311359
I
EXHIBIT
,tA„
Affirmative Action Plan
The City of Round Rock hereby agrees that it will enact
(Name of Applicant)
affirmative action plan. Affirmative action is a management responsibility to take necessary steps
to eliminate the effects of past and present job discrimination, intended or unintended, which is
evident from an analysis of employment practices and policies. It is the policy of the agency that
equal employment opportunity is afforded to all persons regardless of race, color, ethnic origin,
religion, sex or age.
This applicant is committed to uphold all laws related to Equal Employment Opportunity
including, but not limited to, the following.
Title VI of the Civil Rights Act of 1964, which prohibits discrimination because of race, color,
religion, sex or nations origin in all employment practices including hiring, firing, promotion,
compensation and other terms, privileges and conditions of employment.
The Equal Pay Act of 1963, which covers all employees who are covered by the Fair Labor
Standards Act. The act forbids pay differentials on the basis of sex.
The Age Discrimination Act, .which prohibits discrimination because of age against anyone
between the ages of 50 and 70.
Federal Executive Order 11246, which requires every contract with Federal financial assistance to
contain a clause against discrimination because of race, color, religion, sex or national origin.
Administration on Aging Program Instruction AoA PI-75-11, which requires all grantees to
develop affirmative action plans. Agencies, which are part of an "umbrella agency," shall develop
and implement an affirmative action plan for single organizational unit on aging. Preference for
hiring shall be given to qualified older persons (subject to requirements of merit employment
systems).
Section 504 of the Rehabilitation Act of 1973, which states that employers may not refuse to hire
or promote handicapped persons solely because of their disability.
Valerie Francois is the designated person with executive authority responsible
for the implementation of this affirmative action plan. Policy information on affirmative action
and equal employment opportunity shall be disseminated through employee meetings, bulletin
boards, and any newsletters prepared by this agency.
Work Force Analysis: Paid Staff
Total Staff: # Full Time # Part Time
Older Persons (60+) # 36 4.18 % # 17 1.97 %
Minority # 227 26.36% # 18 2.09 %
Women # 220 25.55% # 31 3.60 %
CERTIFICATION
REGARDING DEBARMENT,SUSPENSION,INELIGIBILITY
AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS
Federal Executive Order 12549 requires the Texas Department of Aging and Disability Services(DADS)to screen each covered potential contractor/grantee to
determine whether each has a right to obtain a contract/grant in accordance with federal regulations on debarment,suspension,ineligibility,and voluntary
exclusion. Each covered contractor/grantee must also screen each of its covered subcontractors/providers.
In this certification"contractor/grantee"refers to both contractor/grantee and subcontractor/sub grantee;"contract/grant"refers to both contract/grant and
subcontract/sub grant.
By signing and submitting this certification the potential contractor/grantee accepts the following terms:
1. The certification herein below is a material representation of fact upon which reliance was placed when this contract/grant was entered into. If it is later
determined that the potential contractor/grantee knowingly rendered an erroneous certification,in addition to other remedies available to the federal
govemment,the Department of Health and Human Services,United States Department of Agriculture or other federal department or agency,or the
Texas Department of Aging and Disability Services may pursue available remedies,including suspension and/or debarment.
2. The potential contractor/grantee shall provide immediate written notice to the person to which this certification is submitted if at any time the potential
contractor/grantee learns that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
3. The words"covered contract,""debarred,""suspended,""ineligible,""participant,""person,""principal,""proposal,"and"voluntarily excluded,"as
used in this certification have meanings based upon materials in the Definitions and Coverage sections of federal rules implementing Executive Order
12549. Usage is as defined in the attachment.
4. The potential contractor/grantee agrees by submitting this certification that,should the proposed covered contract/grant be entered into,it shall not
knowingly enter into any subcontract with a person who is debarred,suspended,declared ineligible,or voluntarily excluded from participation in this
covered transaction,unless authorized by the Department of Health and Human Services,United States Department of Agriculture or other federal
department or agency,and/or the Texas Department of Aging and Disability Services,as applicable.
Do you have or do you anticipate having subcontractors/sub grantees under this proposed contract? _X_YES NO
5. The potential contractor/grantee further agrees by submitting this certification that it will include this certification titled"Certification Regarding
Debarment,Suspension,Ineligibility,and Voluntary Exclusion for Covered Contracts and Grants"without modification,in all covered subcontracts
and in solicitations for all covered subcontracts.
6. A contractor/grantee may rely upon a certification of a potential subcontractor/sub grantee that it is not debarred,suspended,ineligible,or voluntarily
excluded from the covered contract/grant,unless it knows that the certification is erroneous. A contractor/grantee must,at a minimum,obtain
certifications from its covered subcontractors/sub grantees upon each subcontract's/sub grant's initiation and upon each renewal.
7. Nothing contained in all the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification
required by this certification document. The knowledge and information of a contractor/grantee is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
8. Except for contracts/grants authorized under paragraph 4 of these terms,if a contractor/grantee in a covered contract/grant knowingly enters into a
covered subcontract/sub grant with a person who is suspended,debarred,ineligible,or voluntarily excluded from participation in the transaction,in
addition to other remedies available to the federal government,Department of Health and Human Services,United State Department of Agriculture,or
other federal department or agency,as applicable,and/or the Texas Department of Aging and Disability Services may pursue available remedies,
including suspension and/or debarment.
CERTIFICATION REGARDING DEBARMENT,SUSPENSION,INELIGIBILITY AND VOLUNTARY EXCLUSION
FOR COVERED CONTRACTS AND GRANTS
Indicate which statement applies to the covered potential contractor/grantee:
_X_The potential contractor/grantee certifies,by submission of this certification,that neither it nor its principals is presently debarred,suspended,proposed
for debarment,declared ineligible,or voluntarily excluded from participation in this contract/grant by any federal department or agency or by the State
of Texas.
The potential contractor/grantee is unable to certify to one or more of the terms in this certification. In this instance,the potential contractor/grantee
must attach an explanation for each of the above terms to which he is unable to make certification. Attach the explanation(s)to this certification.
NAME OF POTENTIAL CONTRACTOR/GRANTEE City of Round Rock
VENDOR ID NO./FEDERAL EMPLOYER'S ID NO. 74-6017485
Mayor Alan McGraw
Signature of Authorized Representative Printed/Typed Name of Authorized Representative
Mayor
Date Title of Authorized Representative
THIS CERTIFICATION IS FOR FFY 2015,PERIOD BEGINNING October 1,2014 and ENDING September 30.2015.
INSTRUCTIONS FOR CERTIFICATION
-2-
1. By signing and submitting this proposal,the prospective contractor/grantee is providing the certification set out
below.
2. The inability of a contractor/grantee to provide the certification required below will not necessarily result in denial
of participation in this covered transaction. The prospective contractor/grantee shall submit an explanation of why
it cannot provide the certification set out below. The certification or explanation will be considered in connection
with the department or agency's determination whether to enter into this transaction. However,failure of the
prospective contractor/grantee to furnish a certification or an explanation shall disqualify such contractor/grantee
from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which reliance was placed when the
department or agency determined to enter into this transaction. If is later determined that the prospective
contractor/grantee knowingly rendered an erroneous certification,in addition to other remedies available to the
Federal Government,the department or agency may terminate this transaction for cause or default.
4. The prospective contractor/grantee shall provide immediate written notice to the department or agency to which
this proposal is submitted if at any time the prospective contractor/grantee learns that its certification was
erroneous when submitted or has become erroneous by reason of changed circumstances.
5. The terms"covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction,"
"participant," "person," "primary covered transaction," "principal," "proposal,"and"voluntarily excluded,"as
used in this clause,have the meanings set out in the Definitions and Coverage sections of the rules implementing
Executive Order 12549. You may contact the department or agency to which this proposal is submitted for
assistance in obtaining a copy of those regulations(13 CFR Part 145).
6. The prospective contractor/grantee agrees by submitting this proposal that,should the proposed covered
transaction be entered into,it shall not knowingly enter into any lower tier covered transaction with a person who
is debarred,suspended,declared ineligible,or voluntarily excluded from participation in this covered transaction,
unless authorized by the department or agency entering into this transaction.
7. The prospective contractor/grantee further agrees by submitting this proposal that it will include the clause titled
"Certification Regarding Debarment,Suspension,Ineligibility and Voluntary Exclusion--Lower Tier Covered
Transactions,"provided by the department or agency entering into this covered transaction, without modification,
in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred,suspended,ineligible,or voluntarily excluded from the covered
transaction,unless it knows that the certification is erroneous. A participant may decide the method and
frequency by which it determines the ineligibility of its principals. Each participant may,but is not required to,
check the Nonprocurement List.
9. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to
render in good faith the certification required by this clause. The knowledge and information of a participant is
not required to exceed that which is normally possessed by a prudent person in the ordinary course of business
dealings.
10. Except for transactions authorized under paragraph 6 of these instructions,if a participant in a covered transaction
knowingly enters into a lower tier covered transaction with a person who is suspended,debarred,ineligible, or
voluntarily excluded from participation in this transaction,in addition to other remedies available to the Federal
Government,the department or agency may terminate this transaction for cause or default.
ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF HEALTH AND
HUMAN SERVICES REGULATION UNDER TITLE VI OF THE CIVIL RIGHTS ACT
OF 1964
City of Round Rock (hereinafter called the "Applicant")
Name of Applicant(Type or Print)
HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L.
880352) and all requirements imposed by or pursuant to the Regulation of the Department of
Health and Human Services (45C.F.R. Part 80) issued pursuant to that title, to the end that, in
accordance with Title VI of that Act and the Regulation, no person in the United States shall, on
the ground of race, color, or national origin, be excluded from participation in, be denied the
benefits of, or be otherwise subjected to discrimination under any program or activity for which
the Applicant receives Federal financial assistance from the Department; and HEREBY GIVES
ASSURANCE THAT it will immediately take any measures necessary to effectuate this
agreement.
If any real property or structure thereon is provided or improved with the aid of Federal financial
assistance extended to the Applicant by the Department, this Assurance shall obligate the
Applicant, or in the case of any transfer of such property, and transferee, for the period during
which the real property or structure is used for a purpose for which the Federal Financial
assistance is extended or for another purpose involving the provision of similar services or
benefits. If any personal property is so provided, this Assurance shall obligate the Applicant for
the period during which it retains ownership or possession of the property. In all other cases, this
Assurance shall obligate the Applicant for the period during which the Federal financial
assistance is extended to it by the Department.
THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all
Federal grants, loans, contracts, property, discounts or other Federal financial assistance
extended after the date hereof to the Applicant by the Department, including installment
payments after such a date on account of applications for Federal financial assistance which were
approved before such date. The Applicant recognizes and agrees that such Federal financial
assistance will be extended in reliance on the representations and agreements made in the
Assurance, and that the United States shall have the right to seek judicial enforcement of this
Assurance. This Assurance is binding on the Applicant, its successors, transferees, and
assignees, and the person or persons whose signatures appear below are authorized to sign this
Assurance on behalf of the Applicant.
City of Round Rock
Date Applicant(Type or Print)
By
221 E. Main Street
Round Rock, TX 78664
Applicant's Mailing Address
CERTIFICATION
REGARDING DEBARMENT,SUSPENSION,INELIGIBILITY
AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS
Federal Executive Order 12549 requires the Texas Department of Aging and Disability Services(DADS)to screen each covered potential contractor/grantee to
determine whether each has a right to obtain a contract/grant in accordance with federal regulations on debarment,suspension,ineligibility,and voluntary
exclusion. Each covered contractor/grantee must also screen each of its covered subcontractors/providers.
In this certification"contractor/grantee"refers to both contractor/grantee and subcontractor/sub grantee;"contract/grant"refers to both contract/grant and
subcontract/sub grant.
By signing and submitting this certification the potential contractor/grantee accepts the following terms:
I. The certification herein below is a material representation of fact upon which reliance was placed when this contract/grant was entered into. If it is later
determined that the potential contractor/grantee knowingly rendered an erroneous certification,in addition to other remedies available to the federal
government,the Department of Health and Human Services,United States Department of Agriculture or other federal department or agency,or the
Texas Department of Aging and Disability Services may pursue available remedies,including suspension and/or debarment.
2. The potential contractor/grantee shall provide immediate written notice to the person to which this certification is submitted if at any time the potential
contractor/grantee learns that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
3. The words"covered contract,""debarred,""suspended,""ineligible,""participant,""person,""principal,""proposal,"and"voluntarily excluded,"as
used in this certification have meanings based upon materials in the Definitions and Coverage sections of federal rules implementing Executive Order
12549. Usage is as defined in the attachment.
4. The potential contractor/grantee agrees by submitting this certification that,should the proposed covered contract/grant be entered into,it shall not
knowingly enter into any subcontract with a person who is debarred,suspended,declared ineligible,or voluntarily excluded from participation in this
covered transaction,unless authorized by the Department of Health and Human Services,United States Department of Agriculture or other federal
department or agency,and/or the Texas Department of Aging and Disability Services,as applicable.
Do you have or do you anticipate having subcontractors/sub grantees under this proposed contract? _X_YES NO
5. The potential contractor/grantee further agrees by submitting this certification that it will include this certification titled"Certification Regarding
Debarment,Suspension,Ineligibility,and Voluntary Exclusion for Covered Contracts and Grants"without modification,in all covered subcontracts
and in solicitations for all covered subcontracts.
6. A contractor/grantee may rely upon a certification of a potential subcontractor/sub grantee that it is not debarred,suspended,ineligible,or voluntarily
excluded from the covered contract/grant,unless it knows that the certification is erroneous. A contractor/grantee must,at a minimum,obtain
certifications from its covered subcontractors/sub grantees upon each subcontract's/sub grant's initiation and upon each renewal.
7. Nothing contained in all the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification
required by this certification document. The knowledge and information of a contractor/grantee is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
8. Except for contracts/grants authorized under paragraph 4 of these terms,if a contractor/grantee in a covered contract/grant knowingly enters into a
covered subcontract/sub grant with a person who is suspended,debarred,ineligible,or voluntarily excluded from participation in the transaction,in
addition to other remedies available to the federal government,Department of Health and Human Services,United State Department of Agriculture,or
other federal department or agency,as applicable,and/or the Texas Department of Aging and Disability Services may pursue available remedies,
including suspension and/or debarment.
CERTIFICATION REGARDING DEBARMENT,SUSPENSION,INELIGIBILITY AND VOLUNTARY EXCLUSION
FOR COVERED CONTRACTS AND GRANTS
Indicate which statement applies to the covered potential contractor/grantee:
_X_The potential contractor/grantee certifies,by submission of this certification,that neither it nor its principals is presently debarred,suspended,proposed
for debamtent,declared ineligible,or voluntarily excluded from participation in this contract/grant by any federal department or agency or by the State
of Texas.
The potential contractor/grantee is unable to certify to one or more of the terms in this certification. In this instance,the potential contractor/grantee
—
must attach an explanation for each of the above terms to which he is unable to make certification. Attach time explanation(s)to this certification.
NAME OF POTENTIAL CONTRACTOR/GRANTEE Star Shuttle
VENDOR ID NO./FEDERAL EMPLOYER'S NO. 74-26247 9/
John P.Walker
Signature of th ze Representative Printedlfyped Name of Authorized Representative
-fig 2- / 7 President/CEO
Date Title of Authorized Representative
THIS CERTIFICATION IS FOR FFY 2015,PERIOD BEGINNING October I.2014 and ENDING September 30,2015.
Affirmative Action Plan
The City of Round Rock hereby agrees that it will enact
(Name of Applicant)
affirmative action plan. Affirmative action is a management responsibility to take necessary steps
to eliminate the effects of past and present job discrimination, intended or unintended, which is
evident from an analysis of employment practices and policies. It is the policy of the agency that
equal employment opportunity is afforded to all persons regardless of race, color, ethnic origin,
religion, sex or age.
This applicant is committed to uphold all laws related to Equal Employment Opportunity
including, but not limited to,the following.
Title VI of the Civil Rights Act of 1964, which prohibits discrimination because of race, color,
religion, sex or nations origin in all employment practices including hiring, firing, promotion,
compensation and other terms,privileges and conditions of employment.
The Equal Pay Act of 1963, which covers all employees who are covered by the Fair Labor
Standards Act. The act forbids pay differentials on the basis of sex.
The Age Discrimination Act, which prohibits discrimination because of age. against anyone
between the ages of 50 and 70.
Federal Executive Order 11246, which requires every contract with Federal financial assistance to
contain a clause against discrimination because of race, color,religion, sex or national origin.
Administration on Aging Program Instruction AoA PI-75-11, which requires all grantees to
develop affirmative action plans. Agencies, which are part of an"umbrella agency," shall develop
and implement an affirmative action plan for single organizational unit on aging. Preference for
hiring shall be given to qualified older persons (subject to requirements of merit employment
systems).
Section 504 of the Rehabilitation Act of 1973, which states that employers may not refuse to hire
or promote handicapped persons solely because of their disability.
Valerie Francois is the designated person with executive authority responsible
for the implementation of this affirmative action plan. Policy information on affirmative action
and equal employment opportunity shall be disseminated through employee meetings, bulletin
boards, and any newsletters prepared by this agency.
Work Force Analysis: Paid Staff
Total Staff: #Full Time #Part Time
Older Persons (60+) # 36 4.18 % # 17 1.97 %
Minority # 227 26.36% # 18 2.09 %
Women # 220 25.55% # 31 3.60 %
AAA program of the
Area
Agency
e11C�` Capital Area Council of
N.") on .£ gmg Governments
Il ft.C.p"An. WWW.capcog.org
AUTHORIZED SIGNATURE FORM
REQUEST FOR PAYMENT
DIRECT PURCHASE OF SERVICE PROGRAM
Name and Address of Contract/Vendor Agency:
City of Round Rock, 221 E. Main Street, Round Rock, TX 78664
Signature of Individuals authorized to sign for request for Reimbursement
Typed Name: Caren Lee Typed Name:
Signature: - Signature:
Typed Name: Typed Name:
Signature: Signature:
I certify that the signatures above are of the individuals authorized to sign the
Request for Reimbursement.
. bt6/
Typed Name and Title of Authorized Official
O_AA; (31_6yLe . 8-aq z-it
Signature of A orized Official Date
mimd 9/02
--..,1 STARSHU-01 NCVDMS
AC4ROc DATE WM/OD/1' M
4..........--- CERTIFICATE OF LIABILITY INSURANCE 2/5/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME: Donna Schultz
American Highways Ins.Agency PHONE 800 935-24421105 FAX 330 659-8912
3250 Interstate Drive INC,No.Ext):( } (A/C.No):(330)
Richfield,OH 44286 ADDAIL
RESS:donna.schultz@ahiains.com
INSURER(S)AFFORDING COVERAGE NAIC p
INSURER A:National Interstate Insurance Company 32620
INSURED INSURER B:
Star Shuttle,Inc.dba Star Shuttle&Charter INSURER C:
P.O.Box 17967 INSURER D:
San Antonio,TX 78217 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR I TYPE OF INSURANCE ifikftZ.
WlBrp POLICY NUMBER '(AMI DY/YYYY)I(MMIDDY)YYYYI I LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000
A X COMMERCIAL GENERAL LIABILITY X X XPP2400020-10 2/112014 2/1/2015 DAMAGE TO RENTED
PREMISES(Ea occurrence) S 250,000
CLAIMS-MADE X OCCUR MED EXP(Any one person) _$ 5,000
PERSONAL&ADV INJURY 3 5,000,000
GENERAL AGGREGATE $ 5,000,000
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 5,000,000
POLICY n NE, n LOC S
AUTOMOBILELIABILITY COMBINED SINGLE LIMIT 1,000,000
(Ea accident) J
A X ANYAUTO X X XPP2400020-10 2/1/2014 2/1/2015 BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS OS
X HIRED AUTOS X MN
O -OWNED PROPERTY DAMAGE $
_AUTOS (Per accident)
$
UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 4,000,000
A X EXCESS LIAR CLAIMS-MADE XEX2400020-11 2/1/2014 2/1/2015 AGGREGATE I 3
DED I RETENTIONS AL Only $
WORKERS COMPENSATION --WC STAN- 0TH-
AND EMPLOYERS'LIABILITY Y N TORY UMITS I I ER _
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 5
OFFICERMI.EMBER EXCLUDED? N I A
(Mandatory in NH) 'E.L DISEASE-EA EMPLOYEE S
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Physical Damage Deductables:
•
Charter Bus vehicles:$20,000 specified perils/collision
All other vehicles:$5,000 specified perils/$10,000 collision
Private passenger/service vehicles$2,500 comprehensivelcollision '
$4M X SIM Excess Auto Liability applies to Charter Buses,Charter Minis,Charter Vans,and School Buses(Charter buses are defined with passenger
capacity>29,Charter Minis are defined as Charters with passenger capacity>15 and<30,Charter Vans are defined as Charters with passenger capacity<16
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Round Rock,its officers and employees THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Cit
CitEast Main ACCORDANCE WITH THE POLICY PROVISIONS.
221Round Rock,TX 78664-5299
AUTHORIZED REPRESENTATIVESE.
x if
A
Q 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
Form 9 Request for Taxpayer Give form to the
(Rev.October 2007) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service
Name(as shown on your income tax return)
City of Round Rock
Ola Business name,if different from above
a
O
2 Check appropriate box: 111Individual/Sole proprietor CICorporation ElPartnership
a
�•�
Exempt
111 Limited liability cornPanY.Enter the tax classification(D=disregarded entity,C=corporation,P=partnership) '❑
payee
o 2 Q Other(see instructions) - Municipality
2 Address(number,street,and apt.or suite no.) Requester's name and address(optional)
a. v 221 East Main Street
.5 City,state,and ZIP code
r°' Round Rock,TX 78664
ai List account number(s)here(optional)
rn
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. For individuals, this is your social security number(SSN). However,for a resident
alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other entities,it is
your employer identification number(EIN).If you do not have a number,see How to get a TIN on page 3. or
Note. If the account is in more than one name,see the chart on page 4 for guidelines on whose Employer identification number
number to enter. 74 6017485
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and
2. I am not subject to backup withholding because: (a)I am exempt from backup withholding, or(b)I have not been notified by the Internal
Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S.person(defined below).
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.
For mortgage interest paid,acquisition or abandonment of secured property, cancellation of debt,contributions to an individual retirement
arrangement(IRA),and generally, payments other than interest and dividends,you are not required to sign the Certification,but you must
provide your correct TIN.See the instructions -page 4. 1
Sign S. of
Here U.S.
S.pensoDate 110. / 'am /
General Instructions Definition of a U.S. person. For federal tax purposes, you are
considered a U.S.person if you are:
Section references are to the Internal Revenue Code unless • An individual who is a U.S. citizen or U.S. resident alien,
otherwise noted.
• A partnership, corporation, company, or association created or
Purpose of Form organized in the United States or under the laws of the United
A person who is required to file an information return with the States,
IRS must obtain your correct taxpayer identification number(TIN) • An estate(other than a foreign estate),or
to report,for example, income paid to you, real estate • A domestic trust(as defined in Regulations section
transactions, mortgage interest you paid, acquisition or 301.7701-7).
abandonment of secured property, cancellation of debt,or Special rules for partnerships.Partnerships that conduct a
contributions you made to an IRA. trade or business in the United States are generally required to
Use Form W-9 only if you are a U.S. person(including a pay a withholding tax on any foreign partners'share of income
resident alien),to provide your correct TIN to the person from such business. Further, in certain cases where a Form W-9
requesting it(the requester)and,when applicable,to: has not been received, a partnership is required to presume that
1. Certify that the TIN you are giving is correct(or you are a partner is a foreign person,and pay the withholding tax.
waiting for a number to be issued), Therefore, if you are a U.S. person that is a partner in a
2. Certify that you are not subject to backup withholding, or partnership conducting a trade or business in the United States,
provide Form W-9 to the partnership to establish your U.S.
3. Claim exemption from backup withholding if you are a U.S. status and avoid withholding on your share of partnership
exempt payee. If applicable,you are also certifying that as a income.
U.S. person, your allocable share of any partnership income from The person who gives Form W-9 to the partnership for
a U.S.trade or business is not subject to the withholding tax on purposes of establishing its U.S.status and avoiding withholding
foreign partners' share of effectively connected income. on its allocable share of net income from the partnership
Note. If a requester gives you a form other than Form W-9 to conducting a trade or business in the United States is in the
request your TIN, you must use the requester's form if it is following cases:
substantially similar to this Form W-9. • The U.S.owner of a disregarded entity and not the entity,
Cat.No.10231X Form W-9 (Rev.10-2007)